The association of insurance status on the probability of transfer for pediatric trauma patients

doi:10.1016/j.jpedsurg.2016.09.036

Journal of Pediatric Surgery

Volume 51, Issue 12, December 2016, Pages 2048-2052

https://doi.org/10.1016/j.jpedsurg.2016.09.036 Get rights and content

Abstract

Background/purpose

The purpose of this study was to evaluate the association of insurance status on the probability of transfer of pediatric trauma patients to level I/II centers after initial evaluation at lower level centers.

Methods

A retrospective review of all pediatric trauma patients (age < 16 years) registered in the 2007–2012 National Trauma Data Bank was performed. Multiple regression techniques controlling for clustering at the hospital level were used to determine the impact of insurance status on the probability of transfer to level I/II trauma centers.

Results

Of 38,205 patients, 33% of patients (12,432) were transferred from lower level centers to level I/II trauma centers. Adjusting for demographics and injury characteristics, children with no insurance had a higher likelihood of transfer than children with private insurance. Children with public or unknown insurance status were no more likely to be transferred than privately insured children. There were no variable interactions with insurance status.

Conclusions

Among pediatric trauma patients, lack of insurance is an independent predictor for transfer to a major trauma center. While burns, severely injured, and younger patients remain the most likely to be transferred, these findings suggest a triage bias influenced by insurance status. Additional policies may be needed to avoid unnecessary transfer of uninsured pediatric trauma patients.

Level of evidence

Case-control study, level III.

Section snippets

Patient cohort selection

The NTDB is maintained by the American College of Surgeons (ACS) and is the largest collection of trauma registry data in the United States. We performed a retrospective analysis of the 2007–2012 NTDB evaluating pediatric trauma patients age < 16 years (Fig. 1). Patients initially evaluated in the emergency department (ED) of an ACS level III or IV or state level III, IV, or non-trauma centers were included for the analysis. We excluded patients who were dead on arrival or died in the emergency

Patient characteristics

A total of 38,205 patients were included in the study (Fig. 1). The majority of patients was admitted (n = 25,773, 67.5%) to a level III, IV or non-trauma center while 32% (12,432) were transferred to a level I or II trauma center. Patient characteristics are described in Table 1. The median patient age was 7 years (range 0–15) and the majority of patients was male. Most patients had private insurance followed by public insurance. Falls were the most common mechanism of injury. The majority of

Discussion

In this population study of pediatric trauma patients, we found that after controlling for clinical and injury characteristics, uninsured children were more likely to be transferred to a major trauma center. Additionally, among less severely injured patients, uninsured children and black children were more likely to be transferred than privately insured children and white children respectively.

Our findings suggest that there may be factors contributing to the decision to transfer that are not

Conclusions

We found that among pediatric trauma patients, lack of insurance was associated with transfer to higher level trauma centers even after controlling for clinical and injury characteristics such as burns, severe injury, and younger age. These findings suggest there may be a triage bias influenced by insurance status. Multicenter prospective observational studies evaluating adherence to transfer guidelines within trauma systems are needed to further evaluate whether non-clinical factors may be

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References (41)

J.C. Densmore et al.
Outcomes and delivery of care in pediatric injury
J Pediatr Surg
(2006)
M. Segui-Gomez et al.
Pediatric trauma care: an overview of pediatric trauma systems and their practices in 18 US states
J Pediatr Surg
(2003)
T.A. Oyetunji et al.
Treatment outcomes of injured children at adult level 1 trauma centers: are there benefits from added specialized care?
Am J Surg
(2011)
D.K. Nakayama et al.
Differences in trauma care among pediatric trauma centers and nonpediatric trauma center
J Pediatr Surg
(1992)
S.D. Goldstein et al.
Secondary overtriage in pediatric trauma: can unnecessary patient transfers be avoided?
J Pediatr Surg
(2015)
S.A. Engum et al.
Prehospital triage in the injured pediatric patient
J Pediatr Surg
(2000)
J. Parks et al.
Financial triage in transfer of trauma patients: a myth or a reality?
Am J Surg
(2009)
N.H. Greene et al.
Variation in pediatric traumatic brain injury outcomes in the United States
Arch Phys Med Rehabil
(2014)
L.D. Cassidy et al.
Health disparities analysis of critically ill pediatric trauma patients in Milwaukee, Wisconsin
J Am Coll Surg
(2013)
R.A. Falcone et al.
Disparities in child abuse mortality are not explained by injury severity
J Pediatr Surg
(2007)

H. Rosen et al.

Lack of insurance negatively affects trauma mortality in US children

J Pediatr Surg

(2009)

T. Locke et al.

The impact of transfer on pediatric trauma outcomes

J Pediatr Surg

(2016)

S.S. Short et al.

Insurance type, not race, predicts mortality after pediatric trauma

J Surg Res

(2013)

F.A. White et al.

Care without coverage: is there a relationship between insurance and ED care?

J Emerg Med

(2007)

M. Heron

Deaths: leading causes for 2013

Natl Vital Stat Rep

(2007)

S.M. Sasser et al.

Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on field triage, 2011

Centres Dis Control Prev MMWR

(2012)

N.E. Wang et al.

The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011

J Trauma Acute Care Surg

(2013)

E.J. MacKenzie et al.

A national evaluation of the effect of trauma-center care on mortality

N Engl J Med

(2006)

D. Gomez et al.

Definitive care in level 3 trauma centres after severe injury: a comparison of clinical characteristics and outcomes

Injury

(2015)

D.A. Potoka et al.

Improved functional outcome for severely injured children treated at pediatric trauma centers

J Trauma Inj Infect Crit Care

(2001)

Cited by (20)

Secondary Undertriage of Pediatric Trauma Patients Across the United States Emergency Departments
2024, Journal of Surgical Research
The American College of Surgeons has developed evidence-based guidelines to triage the care of severely injured children to Level 1 and 2 trauma centers. Undertriage is the treatment of patients at facilities not equipped to treat the patient’s injuries appropriately. We sought to evaluate the association between patient and hospital characteristics and secondary undertriage in children after major trauma.
We performed a retrospective cohort study using the 2019 Nationwide Emergency Department Sample. Patients aged less than 18 y were included if they presented to a Level 3 or nontrauma center (NTC) and were diagnosed with a traumatic injury with an injury severity score >15 based on International Classification of Diseases 10 codes. Our primary outcome was secondary undertriage, defined as inpatient admission to a Level 3 or NTC. We developed generalized linear models with inverse-probability survey weighting to determine the association between patient and hospital characteristics and the primary outcome.
Of 6572 weighted patients, 982 (15%) were undertriaged. Undertriage was significantly associated with older age (13 versus 7, P value < 0.001), metropolitan location (86% versus 68%, P < 0.001), and major abdominal injuries (19% versus 11%, P = 0.011). After multivariable adjustment, secondary undertriage was significantly associated with patients aged 6-10 y (adjusted odds ratio [aOR]: 2.47, P = 0.002) compared to patients aged 15-17 y, penetrating injury (aOR: 1.70, P = 0.011), major chest injury (aOR: 2.10, P = 0.014), and presentation at a teaching hospital (aOR: 5.66, P < 0.001).
After major trauma, a significant proportion of children are secondarily undertriaged at teaching NTCs. Level 1 and 2 trauma centers must partner with lower-level trauma centers to ensure children receive equitable care.
Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients
2023, Journal of Surgical Research
Citation Excerpt :
In addition to injury severity, a variety of other factors have been reported to impact the likelihood of a patient being transferred to a higher level trauma center including patient demographics (e.g., gender, age, and race),2,3,8-15 payer status,8-12,15-23 hospital characteristics,16,21,24 time of day,11,25 and specialist availability.2 Findings regarding the relationship between payer status and secondary overtriage have been mixed.1,2,8,10,13,17,18,23 Some studies have found that, even after adjusting for injury characteristics and other clinical and demographic characteristics, patients without commercial insurance were more likely to be transferred to a higher level trauma center.8,10,17,18
Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers.
Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles.
Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage.
In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.
Pediatric Injury Transfer Patterns During the COVID-19 Pandemic: An Interrupted time Series Analysis
2023, Journal of Surgical Research
With the expected surge of adult patients with COVID-19, the Children's Hospital Association recommended a tiered approach to divert children to pediatric centers. Our objective was understanding changes in interfacility transfer to Pediatric Trauma Centers (PTCs) during the first 6 mo of the pandemic.
Children aged < 18 y injured between January 1, 2016 and September 30, 2020, who met National Trauma Databank inclusion criteria from 9 PTCs were included. An interrupted time-series analysis was used to estimate an expected number of transferred patients compared to observed volume. The “COVID” cohort was compared to a historical cohort (historical average [HA]), using an average across 2016-2019. Site-based differences in transfer volume, demographics, injury characteristics, and hospital-based outcomes were compared between cohorts.
Twenty seven thousand thirty one/47,382 injured patients (57.05%) were transferred to a participating PTC during the study period. Of the COVID cohort, 65.4% (4620/7067) were transferred, compared to 55.7% (3281/5888) of the HA (P < 0.001). There was a decrease in 15-y-old to 17-y-old patients (10.43% COVID versus 12.64% HA, P = 0.003). More patients in the COVID cohort had injury severity scores ≤ 15 (93.25% COVID versus 87.63% HA, P < 0.001). More patients were discharged home after transfer (31.80% COVID versus 21.83% HA, P < 0.001).
Transferred trauma patients to Level I PTC increased during the COVID-19 pandemic. The proportion of transferred patients discharged from emergency departments increased. Pediatric trauma transfers may be a surrogate for referring emergency department capacity and resources and a measure of pediatric trauma triage capability.
Social determinants of health as drivers of inequities in pediatric injury
2022, Seminars in Pediatric Surgery
A child's social determinants of health (SDH), including their neighborhood environment, insurance status, race and ethnicity, English language proficiency and geographic location, all significantly impact their risk of injury and outcomes after injury. Children from socioeconomically disadvantaged neighborhoods experience overall higher rates of injury and different types of injuries, including higher rates of motor vehicle-, firearm-, and violence-related injuries. Similarly, children with public insurance or no insurance, as a proxy for lower socioeconomic status, experience higher rates of injuries including firearm-related injuries and non-accidental trauma, with overall worse outcomes. Race and associated racism also impact a child's risk of injury and care received after injury. Black children, Hispanic children, and those from other minority groups disproportionately experience socioeconomic disadvantage with sequelae of injury risk as described above. Even after controlling for socioeconomic status, there are still notable disparities with further evidence of racial inequities and bias in pediatric trauma care after injury. Finally, where a child lives geographically also significantly impacts their risk of injury and available care after injury, with differences based on whether a child lives in a rural or urban area and the degree of state laws regarding injury prevention. There are clear inequities based on a child's SDH, most predominantly in a child's risk of injury and the types of injuries they experience. These injuries are preventable and the SDH provide potential upstream targets in injury prevention efforts.
Association of Race With Postoperative Mortality Following Major Abdominopelvic Trauma in Children
2022, Journal of Surgical Research
Citation Excerpt :
Transfer of critically injured children to level I and II trauma centers after presentation and stabilization in lower-level centers is associated with improved mortality.28 To that end, mortality levels are lower for children treated in pediatric trauma centers compared to those treated in adult trauma centers.28 Children treated at pediatric trauma centers have improved outcomes ranging from decreased mortality, improved management of solid organ injury, better access to subspecialists, decreased hospital charges, increased referral rates to rehabilitation facilities, and improved functional outcomes.29,30
The leading cause of mortality among children is trauma. Race and ethnicity are critical determinants of pediatric postsurgical outcomes, with minority children generally experiencing higher rates of postoperative morbidity and mortality than White children. This pattern of poorer outcomes for racial and/or ethnic minority children has also been demonstrated in children with head and limb traumas. While injuries to the abdomen and pelvis are not as common, they can be life-threatening. Racial and/or ethnic differences in outcomes of pediatric abdominopelvic operative traumas have not been examined. Our objective was to determine whether disparities exist in postoperative mortality among children with major abdominopelvic trauma.
We performed a retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Patients were included if they were < 18 years, sustained a major abdominopelvic injury, and underwent subsequent surgical intervention. Our primary outcome was inpatient mortality, comparing children of different race and/or ethnicity.
We identified a weighted cohort of 13,955 children, of whom 6765 (48.5%) were White, 3614 (25.9%) Black, and 2647 (19.0%) Hispanic. After adjusting for covariates, Black children were 94% more likely to die than their White peers (3.3% versus 1.6%, adjusted-RR:1.94, 95%CI: 1.33-2.82, P = 0.001). Hispanic children (adjusted-RR:1.99, 95%CI: 1.36-2.91, P < 0.001) and those of other race and/or ethnicity (adjusted-RR: 2.02, 95%CI:1.20-3.40, P = 0.008) were also more likely to die compared to their White peers.
Black and Hispanic children who require operative intervention following major abdominopelvic trauma have a higher risk of postoperative mortality compared with White children.
Secondary Overtriage of Trauma Patients: Analysis of Clinical and Geographic Patterns
2020, Journal of Surgical Research
The purpose of a trauma system is to match patients’ needs with hospitals' ability to care for them, recognizing that the highest levels of care cannot be provided in all locations. This means that some patients will need to be transferred from a local facility to a higher level of care. Unnecessary transfers are expensive and inconvenient to patients and families. The aim of this study is to analyze the pattern of secondary transfers in a regional trauma system.
This is a retrospective analysis. We included patients aged 16 y and older who were transferred to University of Alabama at Birmingham Hospital between 2014 and 2018. We conducted bivariate and multivariate logistic regression analysis to identify clinical and organizational predictors of requiring a critical intervention, early discharge, intensive care unit admission, and mortality. Rather than treating each injury as isolated, we analyzed injury patterns.
A total of3824 patients met the inclusion criteria. Of them, 664 patients (17.4%) required a critical intervention, 635 (16.6%) were discharged within 24 h, 1356 (35.5%) were admitted to the intensive care unit, and 172 (4.0%) patients died. Univariate and multivariate analyses revealed many positive associations, with regard to injury pattern, originating center, and insurance status.
There are patterns in the data, and further study is required to understand drivers of secondary overtriage, and how we might be able to address this problem. Reducing the number of unnecessary transfers is a difficult task, which will require engagement at all levels of the trauma system.

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PAPS PaperThe association of insurance status on the probability of transfer for pediatric trauma patients

Abstract

Background/purpose

Methods

Results

Conclusions

Level of evidence

Section snippets

Patient cohort selection

Patient characteristics

Discussion

Conclusions

Acknowledgements

J Pediatr Surg

J Pediatr Surg

Am J Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Am J Surg

Arch Phys Med Rehabil

J Am Coll Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Surg Res

J Emerg Med

Deaths: leading causes for 2013

Natl Vital Stat Rep

Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on field triage, 2011

Centres Dis Control Prev MMWR

The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011

J Trauma Acute Care Surg

A national evaluation of the effect of trauma-center care on mortality

N Engl J Med

Definitive care in level 3 trauma centres after severe injury: a comparison of clinical characteristics and outcomes

Injury

Improved functional outcome for severely injured children treated at pediatric trauma centers

J Trauma Inj Infect Crit Care

PAPS Paper
The association of insurance status on the probability of transfer for pediatric trauma patients